Geriatric MedicineTier 1Disease (DEADMAN)

Orthostatic hypotension

Description

Sustained drop in BP on standing - >=20mmHg systolic or >=10mmHg diastolic within 3 minutes of standing
Major cause of falls, syncope, and functional decline in older adults; often multifactorial

Autonomic failure

Primary - Parkinson's disease, multiple system atrophy, pure autonomic failure, Lewy body dementia
Secondary - diabetic autonomic neuropathy, amyloidosis

Non-autonomic (more common in general geriatric population)

Volume depletion - dehydration, diuretics, haemorrhage, sepsis
Drugs - antihypertensives, alpha blockers (esp. for BPH), TCAs, antipsychotics, Parkinson's medications, nitrates
Prolonged bed rest/deconditioning
Postprandial hypotension - splanchnic pooling, esp. after carbohydrate-rich meals
Adrenal insufficiency, dysautonomia from acute illness

Lying-to-standing BP - measure supine after 5 min rest, then at 1 and 3 min standing
Symptoms - dizziness, presyncope, syncope, falls, cognitive slowing on standing (may be asymptomatic in autonomic failure - "silent" OH)
Distinguish neurogenic (autonomic failure - fixed HR despite BP drop) vs non-neurogenic (compensatory tachycardia present)
Look for supine hypertension - common paradox in autonomic failure, complicates treatment
Screen for red flags of underlying neurodegenerative disease if new/progressive - parkinsonism, cognitive change, urinary dysfunction

Sequence

1. Review and deprescribe - antihypertensives, alpha blockers, sedating psychotropics; treat volume depletion

2. Non-pharmacological first-line

Adequate fluid intake, increased salt (if not contraindicated by HF/renal disease)
Slow postural changes, dorsiflex feet before standing
Compression garments (waist-high preferred over stockings alone)
Small, frequent, low-carbohydrate meals if postprandial component
Raise head of bed 10-20 degrees overnight (reduces nocturnal supine hypertension + nocturnal natriuresis)

3. Pharmacological if refractory and impacting function

Fludrocortisone - volume expansion; watch for supine HTN, oedema, hypokalaemia
Midodrine - alpha agonist, avoid in supine hypertension, do not dose before lying down
Droxidopa - selected refractory neurogenic OH (limited access)

Manage supine hypertension

Avoid long-acting antihypertensives at night if pressor agents used for daytime OH
Short-acting agents at bedtime only if supine HTN severe

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